Defining an ‘Advanced Intensive Interaction Practitioner’?

According to a recent research paper about the use of Intensive Interaction across day services for adults with profound and multiple learning disabilities in Sheffield by Prof. Judy Clegg et al  'Examining the impact of a city-wide intensive interaction staff training program for adults with profound and multiple learning disability ...*':

‘Structures supporting the use of Intensive Interaction centred on training and the role of the advanced practitioner … [this] role was viewed as vital … The advanced practitioner role was an important factor in maintaining a focus on Intensive Interaction’

This made me think about some previous attempts (mine and others) at defining the essential nature of any such advanced Intensive Interaction practices or practitioners. I then remembered Melanie Nind & Mary Kellet's three defined levels of ‘Interactive style and practice of Intensive Interaction’ as set out in their book Implementing Intensive Interaction in Schools**. From their work I have had a go at using and or adapting/simplifying these levels, and came up with the three levels below:

Emerging Intensive Interaction Practice: when the Intensive Interaction practice is increasingly well-rehearsed, but might often be described as constrained or formulaic.

Established Intensive Interaction Practice: when the Intensive Interaction practice is enacted with increasing confidence, is clearly based on Intensive Interaction principles, and as such is clearly responsive and sensitive in nature.

and then there was ....

Advanced Intensive Interaction Practice: when the Intensive Interaction practice is fluid and highly sensitive, and is informed by reflective thinking within and around a broad range of Intensive Interaction engagements.

So in Leeds we are thinking about how, in more detail, we could say with some certainty that a practitioner had attained the correct level to be such an ‘Advanced Intensive Interaction Practitioner’, and it is my view that the following aspects of ‘Advanced Intensive Interaction practice' should be observable in their practices:

1. Their use of observation is skilful, sensitive and reflective in nature.

2. Their interactive practice is fluid and sensitive, and is informed by the active use of observation and associated reflective thinking within and between interactions.

3. Their physical positioning during practice is adapted as and when necessary based on current or previous reflective observations.

4. The tempo of their interactive practice is well-paced, and is skilfully employed to maximise the participation of the student or service user.

5. The practitioner uses selective imitation and provides appropriate presentations for the student or service user to join in with or reflect back. 

6. The practitioner uses a broad range of vocal intonation and/or articulation (when appropriate) to facilitate the engagement of the student or service user.

7. The practitioner’s interactive routines are varied in content and intensity.

8. The practitioner is able to engage and sustain interactions with the most challenging and socially isolated students or service users.

9. A student or service user’s communications of complex and/or negative, as well as positive, emotions are handled and responded to confidently by the practitioner.

10. The practitioner is reflectively aware of their own interactive practices, their insights being gained through regular non-judgemental self-appraisal and shared feedback, and they can articulate their reflective thinking to others.

Do these 10 criteria sound about right? 

... and if so, I think that we should also ask ourselves how we could set about robustly evidencing (and even certificating) an Intensive Interaction practitioner's attainment of such an 'advanced practice' level; especially as having such 'Advanced Practitioners' across a service is evidenced in peer-reviewed research (by Clegg at al) as being vital in sustaining the provision of good quality Intensive Interaction for the people we care for and support.

*Clegg, J. , Black, R., Smith, A. & Brumfitt, S. (2018) 'Examining the impact of a city-wide intensive interaction staff training program for adults with profound and multiple learning disability: a mixed methods evaluation', Disability and Rehabilitation. pp. 1-10. ISSN 0963-8288.

**Nind, M. & Kellet, M. (2003) Implementing Intensive Interaction in Schools. David Fulton: London.

‘REACHING OUT TO OTHERS’ with Intensive Interaction in 2019.

It occurred to me recently that, over the last 15 years there has clearly developed a strong (albeit geographically diffuse) community of practice around Intensive Interaction, as well as there now being many different (although sometimes overlapping) local and service based communities of Intensive Interaction practitioners. These local, national and increasingly international communities of practice collectively have many members; some members still novice or peripheral (i.e. those at the start of their Intensive Interaction journeys), some others being longstanding and core members of their groups. It has been a real joy to see these self-supporting communities develop over the years.

But in line with the theme we had for our 2018 Intensive Interaction Week i.e. 'Reaching Out to Others’, my mind has started to move ahead into 2019 (not before time!) … and I think we, as a genuinely strong and stable (where have I heard that before!) community need to look with more vigour outside what could be seen as a potentially comfortable and self-referencing ‘echo-chamber’. I think that we need to more actively 'Reach Out' and embrace others, be they individuals, groups, services or even entire disciplines, and get our Intensive Interaction message more and more ‘out there’.

But how should we go about doing this (I hear you ask) ... well I think we need to actively set out to make links with those who might metaphorically and/or literally open the door for us. So rather than us just speaking to each other (which we will still continue to do), we should also be looking to get ourselves invited into other people’s meetings, their various networking events, get-togethers, away-days, conferences, on-line groups, webinars, etc. 

In our Intensive Interaction community we have parents, siblings and other family members, foster carers, teachers, teaching assistants, residential care staff, respite care staff, day service staff, support staff, speech & language therapists, nurses, doctors, occupational therapists, physiotherapists, other therapists (e.g. music and drama), counsellors, clinical and educational psychologists, psychiatrists, social workers, service managers, personal assistants, care managers, directors and trustees, and many more besides. So I think that we should all be making resolutions that 2019 will be the Intensive Interaction year of 'Reaching Out to Others’. Lets get our Intensive Interaction story to be the socially interactive 'cuckoo in the nest’ of all these other groups and professional disciplines who desperately need to hear what we have to say (even if they don't realise that just yet).

So perhaps these might be some useful questions to ask ourselves: 

1. Outside of Intensive Interaction, which other groups am I a member of, or work with? 

2. What kind of training, information or networking events or media do they use? 

3. Who organises these, and how might I contact them? 

4. Can I draft a short presentation proposal about Intensive Interaction? (Yes you can!) 

5. What is stopping me doing this? (Nothing!) 

So, let’s get Intensive Interaction out there ... Let’s all 'Reach Out to Others' in 2019!

'A Different Way of Thinking': a film for Leeds Autism Service.

As I shared a link to a film about a man with profound and multiple learning difficulties in last week's blog ('Understanding Suraj' by Ian Ingram of NL Film Productions), I thought I might do the same in this week's Blog. 

This film, 'A Different Way of Thinking', was made by Midgley Media for the Leeds Autism Service (and is really a bit of an unabashed promotional film for their services!), but some aspects of the film are really interesting in terms of looking at Autism, specifically from a parental point of view. You can see what you think via a link at: 

https://vimeo.com/207459093

p.s. the very best 'interactive' wishes for you in the New Year, and across all of 2019! 

'Understanding Suraj' - a film now available on YouTube as a free resource

'Understanding Suraj' is a 45 minute film by Ian Ingram of NL Film Productions. It was initially published as a DVD in 2015. This film is about a young man called Suraj, and also about how he was reached through Intensive Interaction ... and it has now been generously gifted by Ian as a free learning/teaching resource that is available on YouTube at: 

https://www.youtube.com/watch?v=mIeuaOn_70c

This film is one that I have used (in part) in a number of training sessions, most recently to teach Clinical Psychologists in training about working proactively with people with profound and multiple learning disabilities to promote contact and social engagement through Intensive Interaction. 

There is a whole section on Intensive Interaction ('Making Contact' from 22.35 - 30.51). It can certainly have a powerful impact when presented in the right form and context.

So I would just like to thank Ian for all his hard work on this project, and again for his clear generosity in gifting this film to everyone who cares for and supports people like Suraj -which is very fitting at this time of year.

p.s. and the very best intensively interactive season's greetings to everyone! 

Intensive Interaction Decision Making : Some draft research findings

Over the last few years we (i.e. me and my research assistants Megan Glyde & Gemma Denby) have been looking into the decision making processes of Intensive Interaction practitioners. Below I set out some draft general findings of that research. I would certainly be interested in any views you have about this complex, dynamic and multi-faceted issue:

The broad categories that emerged during our qualitative study into the decision making processes of practitioners (13 qualified Intensive Interaction Coordinators no less!) when applying the general principles of Intensive Interaction, included there being times when:

1. The decision making process could generally be described as ‘conscious’ and/or consciously ‘reflective’ in nature:

Such ‘conscious’ and/or ‘reflective’ considerations being given by an Intensive Interaction practitioner to a number of what they perceived to be significant practice related issues, these potentially differing in their form or focus depending on whether such ‘reflective’ considerations take place:

• Before, or in preparation to social engage with a learner/service user
• When initiating a period of Intensive Interaction with a learner/service user
• During the period of Intensive Interaction with a learner/service user
• Approaching or at the point of disengagement from a period of Intensive Interaction with a learner/service user
• After disengaging from a period of Intensive Interaction with a learner/service user; with the form of these reflections being dependant on whether any post-engagement reflections were conducted individually, or if they were in some way structured (e.g. within a video reflection protocol) and supported by colleagues/peers.

2. The decision making process could generally be described as ‘intuitive’ or ‘unconscious’ in nature: 

Such ‘intuitive’ or ‘unconscious’ decision making being evident when the Intensive Interaction practitioner stated that they are affectively ‘attuned’, or ‘tuned-in’ to, or interactively ‘going with the flow’ with a learner/service user during a sustained period of Intensive Interaction. 

With some learners/service users such a state of optimal emotional and interactive attunement was reported to be built relatively easily and relatively quickly, whilst with others such an attuned state could take longer to attain, and be less securely developed.

3. The decision making process could be described as dynamically moving between ‘intuitive’ and ‘conscious’ decision making:

Any such movement between different levels or states of conscious or intuitive decision making was seen to be triggered as and when certain issues arose that were registered ‘in the moment’ as significant by the Intensive Interaction practitioner. The reasons given by practitioners for such movements between different cognitive states being associated with perceived variations in a learner/service user’s levels of engagement, or with perceived changes (current, imminent or desired) in the learner/service user’s levels of arousal or behaviour, or if 'moving on' in some way (currently or desired) from the shared and mutually negotiated interactive repertoire. 

From an attuned and intuitive state of engagement, practitioners reported at times becoming more conscious or consciously reflective in their thinking as a period of Intensive Interaction, for some reason, moved out of a state of predictable and optimal flow. 

Movement from conscious decision making to a state of more intuitive practicing of Intensive Interaction seemingly taking place when a process of emotional and behavioural attunement successfully developed between the practitioner and a learner/service user across a period of Intensive Interaction.

p.s. as I write up more of the findings I will share these with you in 2019 - Happy New Year!

Thinking about the fidelity of Intensive Interaction practices

As more and more people are now finding out, Intensive Interaction gives us a process through which we can develop genuine social inclusion for people with communication and/or social impairments ... and then, by being engaged in that socially inclusive process,  supporting the development of a person's social communication and sociability; nothing difficult or contentious there then. 

But a question I have recently been asking myself is: how can we most precisely define the naturalistic, and often fluid, 'in the moment' and open-ended process of Intensive Interaction in way that can really nail its fidelity, so that when people (e.g. in research studies) say they are doing Intensive Interaction (and possibly trying to measure its subsequent outcomes), we can be sure (to the best degree possible) that it really is the best quality Intensive Interaction that could be provided (e.g. by someone who is a competent, experienced and reflective practitioner i.e. by someone who might be described as an 'advanced' Intensive Interaction practitioner? see last week's 03/1/18 Blog). 

Now Fidelity can be a tricky thing, but in very general terms it is defined as: 'the extent to which [the] delivery of an intervention adheres to the protocol or program model originally developed'*. So, we already have a very clear starting point there.

Therefore I think that any fidelity measures that might be useful in any Intensive Interaction research should combine two things; evidence of the use of the Fundamentals of Communication** (i.e. what the practitioner actually does) and Melanie Nind's 5 Central Features of Intensive Interaction*** (i.e. how the practitioner actually does what they do).

As most of us know, the 'fundamentals of communication' have been clearly set out by Hewett and Nind, most recently in the Intensive Interaction Handbook (2nd Ed, p.26) as: enjoying being with another person; using and understanding eye contacts; developing the ability to attend to that person; using and understanding facial expressions; learning to do sequences of activity with a person; using and understanding other non-verbal communications; taking turns in exchanges of behaviour; using and understanding physical contacts; sharing personal space; learning to regulate and control arousal levels; and vocalising and using vocalisations meaningfully (including speech).

Nind’s 5 central features of Intensive Interaction (set out in 'Efficacy of Intensive Interaction ...' 1996) are also referenced in the Intensive Interaction Handbook (2nd Ed, p.14) as:

1.  The creation of mutual pleasure and interactive games: being together with the purpose of enjoying each other (please also see my blog of 02/07/18 for a bit more on this one!)

2.   Staff adjusting their interpersonal behaviours in order to become more engaging & meaningful for the person

3.   Interactions flowing naturally in time: with pauses, repetitions and blended rhythms

4.   The attribution of intentionality: responding to a person’s  behaviour as if it were communicatively significant

5.   The use of contingent responding: following a person’s lead and sharing control of the activity

But, another thought: perhaps we should all be more thoughtful about the fidelity of our Intensive Interaction practices? Perhaps fidelity is a useful concept for us all to hold in our minds (and not just something for researchers to think about).

Perhaps we should all ask ourselves if we and our colleagues really are doing the best quality Intensive Interaction ... or something else, something with less fidelity 'to the protocol or program model originally developed' ... and therefore something potentially less truly intensively interactive? 

*Mowbray et al (2003) 'Fidelity Criteria: Development, Measurement, and Validation', American Journal of Evaluation, 24 (3), p.315-340.
**Hewett, D. Ed (2018) The Intensive Interaction Handbook (2nd Ed). Sage: London.
***Nind, M. (1996) ‘Efficacy of Intensive Interaction; Developing sociability and communication in people with severe and complex learning difficulties using an approach based on caregiver-infant interaction’, European Journal of Special Educational Needs, 11 (1), 48-66.

A new research paper on 'City Wide' Intensive Interaction training

I recently read a research paper published in the journal of Disability and Rehabilitation by researchers Judy Clegg, Rachael Black, Antoin Smith and Shelagh Brumfitt. The paper is called:

'Examining the impact of a city-wide Intensive Interaction staff training program for adults with profound and multiple learning disability: a mixed methods evaluation' 

[2018, but still only available on-line I think].

In this study, 7 staff were trained as ‘Intensive Interaction coordinators’; these coordinators then went on to train 120 staff working across a UK city's day centres for people with profound and multiple learning disabilities (PMLD). Some staff with a particular interest in the approach were then given further training, and one-to-one mentoring, and they were then signed off as ‘Advanced Practitioners’ (APs). These APs were then expected to support their colleagues to use I.I., as well as use it themselves. 

The results of this study showed that the Intensive Interaction training had a significant impact on the levels of staff knowledge about the approach, and that this then also changed the staffs' work practices. Indeed, 96% of the participants reported using Intensive Interaction, with 76% also wishing to use the approach with even more people. Using Intensive Interaction was also reported to help staff build better relationships with their service users, giving them more confidence and greater job satisfaction as well. 

However, the implementation of Intensive Interaction was seen to be about more than just having enough well trained staff - there was also a need for a consistent 'core team' of skilled and enthusiastic staff (the APs) who were committed to developing Intensive Interaction. The ‘Advanced Practitioners’ role was viewed as vital in this development and in maintaining staff’s focus on Intensive Interaction across the day centres. 

Support from managers and dedicated staff time to reflect on the use of Intensive Interaction were also valued, as was the completion of session and attainment records and external support from speech and language therapy services. 

This paper identified some implications for future service wide Intensive Interaction interventions: 

• Training staff in Intensive Interaction promotes successful social inclusion for adults with PMLD.

• With Intensive Interaction training staff can identify changes (i.e. positive developments) in the interactive and communicative behaviours of their service users. 

• However, staff need continued support and training to sustain their use of Intensive Interaction. 

• Also, services need to reduce the barriers of staffing, management and organisational structures to enable staff to sustain their use of Intensive Interaction. 

So, I think that this study provides us with clear and robust evidence that a well structured and well supported service level Intensive Interaction programme can be effective in increasing both the social inclusion and communicative progression of people with profound and multiple learning disabilities.

Many thanks then to researchers Judy, Rachael, Antoin and Shelagh. But we need more of this; more research, and more well structured and well supported Intensive Interaction interventions!